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CARDIAC SYNCOPE AFTER SWALLOWING
855
normal. The right eye was blind, with optic atrophy and a fixed dilated pupil. She was immediately started on prednisone 20 mg. t.d.s., and within thirty-six hours there was much improvement. The visual field defect began to shrink, and the visual acuity increased. By March 11, her visual acuity had become normal
(Jl),
and
only
a
minimal
peripheral temporal
field defect
remained. This defect has since disappeared. She has continued to take thyroid gr. 1/2 b.d., but the dosage of prednisone has
now
been reduced
to
10 mg. t.d.s.
has proved instructive. Although decomfailed to save the sight of the right eye, the left pression eye improved after operation and this may have been due to the prednisolone which was being concurrently given. The relapse of the left eye followed five days after stopping prednisolone, and impressive improvement began within thirty-six hours of resuming steroid treatment. Although no firm conclusions can be drawn from a single case, we feel that it is reasonable to attribute this patient’s improvement to steroids; at any rate we do not propose to risk withdrawing treatment a second time. We wish to thank Dr. Denis Brinton for permission to report
This
this
case
case.
The National Hospital for Nervous
Diseases, London, W.C.1.
R. W. HORNABROOK J. C. LEONARD.
PRE-ECLAMPTIC TOXÆMIA
SIR,-Dr. Margaret Robinson (Jan. 25) holds that the ingestion of extra sodium chloride in the diet is successful in the prevention of toxaemia of pregnancy; but I believe that her study has many shortcomings. Because of the large circulation which The Lancet has to the medical profession of this country, I think that this article is more damaging to prospective mothers and to the information of those concerned with their care than any other piece of literature presented to the obstetrician in the past thirty years. We have statistically analysed Dr. Robinson’s data. We found that they were statistically significant in the overall groups. In the age-groups 0-30 and 30-50, the data were significant where toxxmia was commoner among those on salt-poor diets. The data were significant as regards parity only up to para. 4 but were not significant beyond this parity. The neonatal deaths and the presence of oedema showed statistical significance. On the other hand, there was no statistically significant correlation among the prenatal deaths, antenatal bleeding, and antepartum hxmorrhage. We could not differentiate between antenatal bleeding and antepartum haemorrhage. Although statistically significant differences existed between the low-salt and the high-salt group, this does not necessarily mean that the patient was protected against toxaemia because of the high-salt diet just because 70% of the patients on the high-salt diet did not develop a toxxmia according to the definition given in the paper. Some other comparisons might be drawn relative to toxxmia of pregnancy
too.
Chesley (personal communication) has shown that there is a statistically significant correlation between the presence of toxaemia of pregnancy and membership of the Baptist Church. We have been able to show a high incidence of toxaemia of pregnancy in underweight patients-but also in those who are overweight. It thus seems that some other variable existed as a third factor in the group of patients reported by Dr. Robinson. In England, where there still exist difficulties in getting satisfactory nutrients, why could not the variable of nutrition account for the differences noted in her series ? Also, it is not known whether her patients on the increased salt intake were not in various degrees
of salt depletion before the administration of supplemental sodium chloride. It seems as though there was no actual control over the sodium-chloride intake among these patients; they were merely instructed to increase their salt intake. It might be open to some question whether the patients actually complied with the advice offered, and even if they did comply by increasing their intake, they may conceivably have increased it only to a level that would be reached by another group who reduced their sodium-chloride intake.
Even under the strictest metabolic conditions of study hospital patients, there are difficulties in controlling compliance with rigid regimes. The study was not controlled in a hospital, nor were there any biochemical, in
weight,
or
endocrinological investigations.
Department of Obstetrics and Gynecology, School of Medicine, Seattle 5, Washington.
RUSSELL R.
DE
ALVAREZ.
CARDIAC SYNCOPE AFTER SWALLOWING
SIR,-Concerning Dr. James’ interesting paper last may I just mention, for the sake of completeness, a case of a similar syndrome which was published by myself and H. Uiberall.1 week,
A lady, aged 62, had a characteristic Stokes-Adams syndrome with unconsciousness, after swallowing food or fluids first thing in the morning. The electrocardiogram showed signs of sinus bradycardia and ventricular extrasystoles. During the attack, the pulse-rate dropped from about 80 to 44 and the blood-pressure from 220/100 to below 80/0 mm. Hg. The attacks began soon after a bout of tonsillitis. At the time of the hospital investigation it was possible to produce an attack by touching the left posterior arch of the soft palate. After a severe attack there was a refractory phase for over an hour which could be used for the intake of large amounts of food without provoking further attacks. The left tonsillar region was anxsthetised and radium 100 mg. implanted for 3 hours. The attacks increased in intensity for the next 2 or 3 days. On the 7th day a second application of radium was carried out with renewed intensity of attacks lasting about 7 days. From the 8th day onwards after a second insertion of radium the attacks disappeared, and the patient remained free from attacks for the next 91/ months.
V. C. MEDVEI. INDIRECT BILIRUBINÆMIA
SIR, The observation by Danoff et al. (Science, April 4; Lancet, Feb. 8, p. 316) that glucuronic acid and its sodium salt administered to infants with hyperbilirubinxmia resulted in a striking but transient fall in unconjugated bilirubin is of extreme interest to all pxdiatricians. In our work with glucuronic acid we have been unable as yet to demonstrate a significant fall in bilirubin level. However, we wish to call attention to the potential hazard in the use of these preparations in view of the fact that physicians may be tempted to substitute glucuronic-acid therapy for replacement transfusions in newborns with dangerously high serum-bilirubin levels. Should the reported findings be confirmed, there is no indication regarding the fate of the declining serumbilirubin. The possibility has not been excluded that bilirubin is driven from the blood into the tissues, thus increasing the risk of brain damage. Until further investigative work determines the exact pharmacodynamic action of these compounds we feel strongly that physicians should refrain from using them in the newborn. Boston
City Hospital,
Boston 18, Massachusetts, U.S.A. 1.
RUDI SCHMID GLORIA JELIU SYDNEY S. GELLIS.
Medvei, V. C., Uiberall, H. Wien. klin. Wschr, 1938, 51, 234.
normal. The right eye was blind, with optic atrophy and a fixed dilated pupil. She was immediately started on prednisone 20 mg. t.d.s., and within thirty-six hours there was much improvement. The visual field defect began to shrink, and the visual acuity increased. By March 11, her visual acuity had become normal
(Jl),
and
only
a
minimal
peripheral temporal
field defect
remained. This defect has since disappeared. She has continued to take thyroid gr. 1/2 b.d., but the dosage of prednisone has
now
been reduced
to
10 mg. t.d.s.
has proved instructive. Although decomfailed to save the sight of the right eye, the left pression eye improved after operation and this may have been due to the prednisolone which was being concurrently given. The relapse of the left eye followed five days after stopping prednisolone, and impressive improvement began within thirty-six hours of resuming steroid treatment. Although no firm conclusions can be drawn from a single case, we feel that it is reasonable to attribute this patient’s improvement to steroids; at any rate we do not propose to risk withdrawing treatment a second time. We wish to thank Dr. Denis Brinton for permission to report
This
this
case
case.
The National Hospital for Nervous
Diseases, London, W.C.1.
R. W. HORNABROOK J. C. LEONARD.
PRE-ECLAMPTIC TOXÆMIA
SIR,-Dr. Margaret Robinson (Jan. 25) holds that the ingestion of extra sodium chloride in the diet is successful in the prevention of toxaemia of pregnancy; but I believe that her study has many shortcomings. Because of the large circulation which The Lancet has to the medical profession of this country, I think that this article is more damaging to prospective mothers and to the information of those concerned with their care than any other piece of literature presented to the obstetrician in the past thirty years. We have statistically analysed Dr. Robinson’s data. We found that they were statistically significant in the overall groups. In the age-groups 0-30 and 30-50, the data were significant where toxxmia was commoner among those on salt-poor diets. The data were significant as regards parity only up to para. 4 but were not significant beyond this parity. The neonatal deaths and the presence of oedema showed statistical significance. On the other hand, there was no statistically significant correlation among the prenatal deaths, antenatal bleeding, and antepartum hxmorrhage. We could not differentiate between antenatal bleeding and antepartum haemorrhage. Although statistically significant differences existed between the low-salt and the high-salt group, this does not necessarily mean that the patient was protected against toxaemia because of the high-salt diet just because 70% of the patients on the high-salt diet did not develop a toxxmia according to the definition given in the paper. Some other comparisons might be drawn relative to toxxmia of pregnancy
too.
Chesley (personal communication) has shown that there is a statistically significant correlation between the presence of toxaemia of pregnancy and membership of the Baptist Church. We have been able to show a high incidence of toxaemia of pregnancy in underweight patients-but also in those who are overweight. It thus seems that some other variable existed as a third factor in the group of patients reported by Dr. Robinson. In England, where there still exist difficulties in getting satisfactory nutrients, why could not the variable of nutrition account for the differences noted in her series ? Also, it is not known whether her patients on the increased salt intake were not in various degrees
of salt depletion before the administration of supplemental sodium chloride. It seems as though there was no actual control over the sodium-chloride intake among these patients; they were merely instructed to increase their salt intake. It might be open to some question whether the patients actually complied with the advice offered, and even if they did comply by increasing their intake, they may conceivably have increased it only to a level that would be reached by another group who reduced their sodium-chloride intake.
Even under the strictest metabolic conditions of study hospital patients, there are difficulties in controlling compliance with rigid regimes. The study was not controlled in a hospital, nor were there any biochemical, in
weight,
or
endocrinological investigations.
Department of Obstetrics and Gynecology, School of Medicine, Seattle 5, Washington.
RUSSELL R.
DE
ALVAREZ.
CARDIAC SYNCOPE AFTER SWALLOWING
SIR,-Concerning Dr. James’ interesting paper last may I just mention, for the sake of completeness, a case of a similar syndrome which was published by myself and H. Uiberall.1 week,
A lady, aged 62, had a characteristic Stokes-Adams syndrome with unconsciousness, after swallowing food or fluids first thing in the morning. The electrocardiogram showed signs of sinus bradycardia and ventricular extrasystoles. During the attack, the pulse-rate dropped from about 80 to 44 and the blood-pressure from 220/100 to below 80/0 mm. Hg. The attacks began soon after a bout of tonsillitis. At the time of the hospital investigation it was possible to produce an attack by touching the left posterior arch of the soft palate. After a severe attack there was a refractory phase for over an hour which could be used for the intake of large amounts of food without provoking further attacks. The left tonsillar region was anxsthetised and radium 100 mg. implanted for 3 hours. The attacks increased in intensity for the next 2 or 3 days. On the 7th day a second application of radium was carried out with renewed intensity of attacks lasting about 7 days. From the 8th day onwards after a second insertion of radium the attacks disappeared, and the patient remained free from attacks for the next 91/ months.
V. C. MEDVEI. INDIRECT BILIRUBINÆMIA
SIR, The observation by Danoff et al. (Science, April 4; Lancet, Feb. 8, p. 316) that glucuronic acid and its sodium salt administered to infants with hyperbilirubinxmia resulted in a striking but transient fall in unconjugated bilirubin is of extreme interest to all pxdiatricians. In our work with glucuronic acid we have been unable as yet to demonstrate a significant fall in bilirubin level. However, we wish to call attention to the potential hazard in the use of these preparations in view of the fact that physicians may be tempted to substitute glucuronic-acid therapy for replacement transfusions in newborns with dangerously high serum-bilirubin levels. Should the reported findings be confirmed, there is no indication regarding the fate of the declining serumbilirubin. The possibility has not been excluded that bilirubin is driven from the blood into the tissues, thus increasing the risk of brain damage. Until further investigative work determines the exact pharmacodynamic action of these compounds we feel strongly that physicians should refrain from using them in the newborn. Boston
City Hospital,
Boston 18, Massachusetts, U.S.A. 1.
RUDI SCHMID GLORIA JELIU SYDNEY S. GELLIS.
Medvei, V. C., Uiberall, H. Wien. klin. Wschr, 1938, 51, 234.